Provider Demographics
NPI:1427365741
Name:LASER MD SC
Entity Type:Organization
Organization Name:LASER MD SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:JOSE
Authorized Official - Middle Name:M
Authorized Official - Last Name:RODRIGUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:773-531-9435
Mailing Address - Street 1:1449 W FLETCHER ST
Mailing Address - Street 2:STE 3
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657-2112
Mailing Address - Country:US
Mailing Address - Phone:773-531-9435
Mailing Address - Fax:
Practice Address - Street 1:1449 W FLETCHER ST
Practice Address - Street 2:STE 3
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-2112
Practice Address - Country:US
Practice Address - Phone:773-531-9435
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-08
Last Update Date:2010-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036089962207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty